REGIS TRATION FORM
Social Security Number #__________________
Campus: □STT □STX
Last First Middle Maiden
Physical Address: Local Mailing Address:
Phone: Home ( _) - Work: ( )
Sex: □Male □Female U.S. Citizen □Yes □No
Date of Birth: Permanent Resident
Alien Registration #
Non Resident Alien: Type of Visa □F □J □H
In compliance with federal reporting requirements, UVI must seek to identify the ethnic background of
students enrolled. You are encouraged to supply this information.
□ American Indian/Alaskan
Have you lived in the Virgin Islands for the past twelve (12) months? □ Yes □ No
In what state/country is your permanent residence? _ _____
Year of last attendance at UVI __________________________________________________
I certify that the information given on this form is complete and correct. I acknowledge that deliberate
omissions or falsifications may subject me to immediate dismissal from the University.
Under the provisions of the Family Educational Rights and Privacy Act of 1974, as amended, you have the
right to withhold the disclosure of any directory information.
If you would like that your name not be listed in a directory please indicate: □ Yes □ No
Student’s Signature Date
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